Combination therapy

ABSTRACT

The present invention relates to a method for the production of an antiangiogenic and/or vascular permeability reducing effect in a warm-blooded animal such as a human which is optionally being treated with ionising radiation, particularly a method for the treatment of a cancer, particularly a cancer involving a solid tumour, which comprises the administration of AZD2171 in combination with ZD6126; to a pharmaceutical composition comprising AZD2171 and ZD6126; to a combination product comprising AZD2171 and ZD6126 for use in a method of treatment of a human or animal body by therapy; to a kit comprising AZD2171 and ZD6126; to the use of AZD2171 and ZD6126 in the manufacture of a medicament for use in the production of an antiangiogenic and/or vascular permeability reducing effect in a warm-blooded animal such as a human which is optionally being treated with ionising radiation.

The present invention relates to a method for the production of anantiangiogenic and/or vascular permeability reducing effect in awarm-blooded animal such as a human which is optionally being treatedwith ionising radiation, particularly a method for the treatment of acancer, particularly a cancer involving a solid tumour, which comprisesthe administration of AZD2171 in combination with ZD6126; to apharmaceutical composition comprising AZD2171 and ZD6126; to acombination product comprising AZD2171 and ZD6126 for use in a method oftreatment of a human or animal body by therapy; to a kit comprisingAZD2171 and ZD6126; to the use of AZD2171 and ZD6126 in the manufactureof a medicament for use in the production of an antiangiogenic and/orvascular permeability reducing effect in a warm-blooded animal such as ahuman which is optionally being treated with ionising radiation.

Normal angiogenesis plays an important role in a variety of processesincluding embryonic development, wound healing and several components offemale reproductive function. Undesirable or pathological angiogenesishas been associated with disease states including diabetic retinopathy,psoriasis, cancer, rheumatoid arthritis, atheroma, Kaposi's sarcoma andhaemangioma (Fan et al, 1995, Trends Pharmacol. Sci. 16: 57-66; Folkman,1995, Nature Medicine 1: 27-31). Alteration of vascular permeability isthought to play a role in both normal and pathological physiologicalprocesses (Cullinan-Bove et al, 1993, Endocrinology 133: 829-837; Sengeret al, 1993, Cancer and Metastasis Reviews, 12: 303-324). Severalpolypeptides with in vitro endothelial cell growth promoting activityhave been identified including, acidic and basic fibroblast growthfactors (aFGF & bFGF) and vascular endothelial growth factor-A (VEGF).By virtue of the restricted expression of its receptors, the growthfactor activity of VEGF, in contrast to that of the FGFs, is relativelyspecific towards endothelial cells. Recent evidence indicates that VEGFis an important stimulator of both normal and pathological angiogenesis(Jakeman et al, 1993, Endocrinology, 133: 848-859; Kolch et al, 1995,Breast Cancer Research and Treatment, 36:139-155) and vascularpermeability (Connolly et al, 1989, J. Biol. Chem. 264: 20017-20024).Antagonism of VEGF action by sequestration of VEGF with antibody canresult in inhibition of tumour growth (Kim et al, 1993, Nature 362:841-844).

Receptor tyrosine kinases (RTKs) are important in the transmission ofbiochemical signals across the plasma membrane of cells. Thesetransmembrane molecules characteristically consist of an extracellularligand-binding domain connected through a segment in the plasma membraneto an intracellular tyrosine kinase domain. Binding of ligand to thereceptor results in stimulation of the receptor-associated tyrosinekinase activity which leads to phosphorylation of tyrosine residues onboth the receptor and other intracellular molecules. These changes intyrosine phosphorylation initiate a signalling cascade leading to avariety of cellular responses. To date, at least nineteen distinct RTKsubfamilies, defined by amino acid sequence homology, have beenidentified. One of these subfamilies is presently comprised by thefins-like tyrosine kinase receptor, Flt-1, the kinase insertdomain-containing receptor, KDR (also referred to as Flk-1), and anotherfins-like tyrosine kinase receptor, Flt-4. Two of these related RTKs,Flt-1 and KDR, have been shown to bind VEGF with high affinity (De Vrieset al, 1992, Science 255: 989-991; Terman et al, 1992, Biochem. Biophys.Res. Comm. 1992, 187: 1579-1586). Binding of VEGF to these receptorsexpressed in heterologous cells has been associated with changes in thetyrosine phosphorylation status of cellular proteins and calcium fluxes.

VEGF is a key stimulus for vasculogenesis and angiogenesis. Thiscytokine induces a vascular sprouting phenotype by inducing endothelialcell proliferation, protease expression and migration, and subsequentorganisation of cells to form a capillary tube (Keck, P. J., Hauser, S.D., Krivi, G., Sanzo, K., Warren, T., Feder, J., and Connolly, D. T.,Science (Washington D.C.), 246: 1309-1312, 1989; Lamoreaux, W. J.,Fitzgerald, M. E., Reiner, A., Hasty, K. A., and Charles, S. T.,Microvasc. Res., 55: 29-42, 1998; Pepper, M. S., Montesano, R.,Mandroita, S. J., Orci, L. and Vassalli, J. D., Enzyme Protein, 49:138-162, 1996.). In addition, VEGF induces significant vascularpermeability (Dvorak, H. F., Detrnar, M., Claffey, K. P., Nagy, J. A.,van de Water, L., and Senger, D. R., (Int. Arch. Allergy Immunol., 107:233-235, 1995; Bates, D. O., Heald, R. I., Curry, F. E. and Williams, B.J. Physiol. (Lond.), 533: 263-272, 2001), promoting formation of ahyper-permeable, immature vascular network which is characteristic ofpathological angiogenesis.

It has been shown that activation of KDR alone is sufficient to promoteall of the major phenotypic responses to VEGF, including endothelialcell proliferation, migration, and survival, and the induction ofvascular permeability (Meyer, M., Clauss, M., Lepple-Wienhues, A.,Waltenberger, J., Augustin, H. G., Ziche, M., Lanz, C., Büttner, M.,Rziha, H-J., and Dehio, C., EMBO J., 18: 363-374, 1999; Zeng, H.,Sanyal, S. and Mukhopadhyay, D., J. Biol. Chem., 276: 32714-32719, 2001;Gille, H., Kowalski, J., Li, B., LeCouter, J., Moffat, B, Zioncheck, T.F., Pelletier, N. and Ferrara, N., J. Biol. Chem., 276: 3222-3230,2001).

Quinazoline derivatives which are inhibitors of VEGF receptor tyrosinekinase are described in International Patent Application Publication No.WO 00/47212. In WO 00/47212 compounds are described which possessactivity against VEGF receptor tyrosine kinase (VEGF TTK).

AZD2171 is4-(4-fluoro-2-methylindol-5-yloxy)-6-methoxy-7-(3-(pyrrolidin-1-yl)propoxy)quinazoline:

AZD2171 is Example 240 of WO 00/47212. AZD2171 is a very potentinhibitor of KDR and also has some activity against Flt-1. The IC₅₀value for AZD2171 inhibition of KDR and Flt-1 tyrosine kinase activity,in recombinant enzyme assays in vitro, is <2 nM and 5 nM respectively.AZD2171 has been shown to elicit broad-spectrum anti-tumour activity ina range of models following once-daily oral administration.

In WO 00/47212 it is stated that compounds of the invention: “may beapplied as a sole therapy or may involve, in addition to a compound ofthe invention, one or more other substances and/or treatments. Suchconjoint treatment may be achieved by way of the simultaneous,sequential or separate administration of the individual components ofthe treatment.”

WO 00/47212 then goes on to describe examples of such conjoint treatmentincluding surgery, radiotherapy and various types of chemotherapeuticagent including inhibitors of growth factor function and the vasculardamaging agents described in International Patent ApplicationPublication No. WO 99/02166 such as N-acetylcolchinol-O-phosphate.N-acetylcolchinol-O-phosphate is ZD6126.

Nowhere in WO 00/47212 is the specific combination of AZD2171 and ZD6126suggested.

Nowhere in WO 00/47212 does it state that use of any compound of theinvention therein with other treatments will produce surprisinglybeneficial effects.

Angiogenesis produces neovascularisation in a number of disease statesand reversal of neovascularisation by damaging the newly-formed vascularendothelium is expected to have a beneficial therapeutic effect.International Patent Application Publication No. WO 99/02166 describestricyclic compounds that surprisingly have a selective damaging effecton newly formed vasculature as compared to the normal, establishedvascular endothelium of the host species. This is a property of value inthe treatment of disease states associated with angiogenesis such ascancer, diabetes, psoriasis, rheumatoid arthritis, Kaposi's sarcoma,haemangioma, lymphoedema, acute and chronic nephropathies, atheroma,arterial restenosis, autoimmune diseases, acute inflammation, excessivescar formation and adhesions, endometriosis, dysfunctional uterinebleeding and ocular diseases with retinal vessel proliferation includingmacular degeneration.

Compounds which damage newly formed vasculature are vascular targetingagents (VTAs) and are also known as vascular damaging agents (VDAs).

One such compound described in International Patent ApplicationPublication No. WO 99/02166 is N-acetylcolchinol-O-phosphate, (also knowas(5S)-5-(acetylamino)-9,10,11-trimethoxy-6,7-dihydro-5H-dibenzo[a,c]cyclohepten-3-yldihydrogen phosphate; Example 1 of WO 99/02166), which is referred toherein as ZD6126:

It is believed, though this is not limiting on the invention, thatZD6126 damages newly-formed vasculature, for example the vasculature oftumours, thus effectively reversing the process of angiogenesis. It hasbeen reported that ZD6126 selectively disrupts tumour vasculatureleading to vessel occlusion and extensive tumour necrosis (Davis P D,Hill S A, Galbraith S M, et al. Proc. Am. Assoc. Cancer Res. 2000; 41:329).

In WO 99/02166 it is stated that:

“compounds of the invention may be administered as sole therapy or incombination with other treatments. For the treatment of solid tumourscompounds of the invention may be administered in combination withradiotherapy or in combination with other anti-tumour substances forexample those selected from mitotic inhibitors, for example vinblastine,paclitaxel and docetaxel; alkylating agents, for example cisplatin,carboplatin and cyclophosphamide, antimetabolites, for example5-fluorouracil, cytosine arabinoside and hydroxyurea; intercalatingagents for example adriamycin and bleomycin; enzymes, for exampleasparaginase; topoisomerase inhibitors for example etoposide, topotecanand irinotecan; thymidylate synthase inhibitors for example raltitrexed;biological response modifers for example interferon; antibodies forexample edrecolomab, and anti-hormones for example tamoxifen. Suchcombination treatment may involve simultaneous or sequential applicationof the individual components of the treatment.”

Nowhere in WO 99/02166 does it suggest any combination of a VTA and aVEGF receptor tyrosine kinase inhibitor for the treatment of any diseasestate including cancer.

Nowhere in WO 99/02166 is the specific combination of ZD6126 and AZD2171suggested.

Nowhere in WO 99/02166 does it state that use of any compound of theinvention therein with other treatments will produce surprisinglybeneficial effects.

Unexpectedly and surprisingly we have now found that the particularcompound AZD2171 used in combination with a particular selection fromthe broad description of combination therapies listed in WO 00/47212,namely with ZD6126, produces significantly better effects than any oneof AZD2171 and ZD6126 used alone. In particular, AZD2171 used incombination with ZD6126 produces significantly better effects on solidtumours than any one of AZD2171 and ZD6126 used alone.

Anti-cancer effects of a method of treatment of the present inventioninclude, but are not limited to, anti-tumour effects, the response rate,the time to disease progression and the survival rate. Anti-tumoureffects of a method of treatment of the present invention include butare not limited to, inhibition of tumour growth, tumour growth delay,regression of tumour, shrinkage of tumour, increased time to regrowth oftumour on cessation of treatment, slowing of disease progression. It isexpected that when a method of treatment of the present invention isadministered to a warm-blooded animal such as a human, in need oftreatment for cancer involving a solid tumour, said method of treatmentwill produce an effect, as measured by, for example, one or more of: theextent of the anti-tumour effect, the response rate, the time to diseaseprogression and the survival rate. Anti-cancer effects includeprophylactic treatment as well as treatment of existing disease.

According to the present invention there is provided a method for theproduction of an antiangiogenic and/or vascular permeability reducingeffect in a warm-blooded animal such as a human, which comprisesadministering to said animal an effective amount of AZD2171 or apharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer in a warm-blooded animal such asa human, which comprises administering to said animal an effectiveamount of AZD2171 or a pharmaceutically acceptable salt thereof, before,after or simultaneously with an effective amount of ZD6126 or apharmaceutically acceptable salt thereof.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer involving a solid tumour in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof.

According to a further aspect of the present invention there is provideda method for the production of an antiangiogenic and/or vascularpermeability reducing effect in a warm-blooded animal such as a human,which comprises administering to said animal an effective amount ofAZD2171 or a pharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof; wherein AZD2171 and ZD6126 may each optionallybe administered together with a pharmaceutically acceptable excipient orcarrier.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer in a warm-blooded animal such asa human, which comprises administering to said animal an effectiveamount of AZD2171 or a pharmaceutically acceptable salt thereof, before,after or simultaneously with an effective amount of ZD6126 or apharmaceutically acceptable salt thereof; wherein AZD2171 and ZD6126 mayeach optionally be administered together with a pharmaceuticallyacceptable excipient or carrier.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer involving a solid tumour in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof; wherein AZD2171 and ZD6126 may each optionally be administeredtogether with a pharmaceutically acceptable excipient or carrier.

According to a further aspect of the invention there is provided apharmaceutical composition which comprises AZD2171 or a pharmaceuticallyacceptable salt thereof, and ZD6126 or a pharmaceutically acceptablesalt thereof, in association with a pharmaceutically acceptableexcipient or carrier.

According to a further aspect of the present invention there is provideda combination product comprising AZD2171 or a pharmaceuticallyacceptable salt thereof and ZD6126 or a pharmaceutically acceptable saltthereof, for use in a method of treatment of a human or animal body bytherapy.

According to a further aspect of the present invention there is provideda kit comprising AZD2171 or a pharmaceutically acceptable salt thereof,and ZD6126 or a pharmaceutically acceptable salt thereof.

According to a further aspect of the present invention there is provideda kit comprising:

a) AZD2171 or a pharmaceutically acceptable salt thereof in a first unitdosage form;

b) ZD6126 or a pharmaceutically acceptable salt thereof in a second unitdosage form; and

c) container means for containing said first and second dosage forms.

According to a further aspect of the present invention there is provideda kit comprising:

a) AZD2171 or a pharmaceutically acceptable salt thereof, together witha pharmaceutically acceptable excipient or carrier, in a first unitdosage form;

b) ZD6126 or a pharmaceutically acceptable salt thereof together with apharmaceutically acceptable excipient or carrier, in a second unitdosage form; and

c) container means for containing said first and second dosage forms.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an antiangiogenic and/orvascular permeability reducing effect in a warm-blooded animal such as ahuman.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an anti-cancer effect in awarm-blooded animal such as a human.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an anti-tumour effect in awarm-blooded animal such as a human.

According to a further aspect of the present invention there is provideda combination treatment comprising the administration of an effectiveamount of AZD2171 or a pharmaceutically acceptable salt thereof,optionally together with a pharmaceutically acceptable excipient orcarrier, and the simultaneous, sequential or separate administration ofan effective amount of ZD6126 or a pharmaceutically acceptable saltthereof, optionally together with a pharmaceutically acceptableexcipient or carrier, to a warm-blooded animal such as a human in needof such therapeutic treatment.

Such therapeutic treatment includes an antiangiogenic and/or vascularpermeability effect, an anti-cancer effect and an anti-tumour effect.

A vascular damaging effect is a particular type of antiangiogenic effectwhich results in the damage of newly-formed vasculature.

A combination treatment of the present invention as defined herein maybe achieved by way of the simultaneous, sequential or separateadministration of the individual components of said treatment. Acombination treatment as defined herein may be applied as a sole therapyor may involve surgery or radiotherapy or an additional chemotherapeuticagent in addition to a combination treatment of the invention.

Surgery may comprise the step of partial or complete tumour resection,prior to, during or after the administration of the combinationtreatment with AZD2171 described herein.

Other chemotherapeutic agents for optional use with a combinationtreatment of the present invention include those described in WO00/47212 which is incorporated herein by reference. Such chemotherapymay cover five main categories of therapeutic agent:

(i) other antiangiogenic agents;

(ii) cytostatic agents;

(iii) biological response modifiers (for example interferon);

(iv) antibodies (for example edrecolomab); and

(v) antiproliferative/antineoplastic drugs and combinations thereof, asused in medical oncology; and other categories of agent are:

(vi) antisense therapies;

(vii) gene therapy approaches; and

(ix) immunotherapy approaches.

The administration of a triple combination of AZD2171, ZD6126 andionising radiation may produce effects, such as anti-tumour effects,greater than those achieved with any of AZD2171, ZD6126 and ionisingradiation used alone, greater than those achieved with the combinationof AZD2171 and ZD6126, greater than those achieved with the combinationof AZD2171 and ionising radiation, greater than those achieved with thecombination of ZD6126 and ionising radiation.

According to the present invention there is provided a method for theproduction of an antiangiogenic and/or vascular permeability reducingeffect in a warm-blooded animal such as a human, which comprisesadministering to said animal an effective amount of AZD2171 or apharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof, and before, after or simultaneously with aneffective amount of ionising radiation.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer in a warm-blooded animal such asa human, which comprises administering to said animal an effectiveamount of AZD2171 or a pharmaceutically acceptable salt thereof, before,after or simultaneously with an effective amount of ZD6126 or apharmaceutically acceptable salt thereof, and before, after orsimultaneously with an effective amount of ionising radiation.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer involving a solid tumour in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof, and before, after or simultaneously with an effective amount ofionising radiation.

According to a further aspect of the present invention there is provideda method for the production of an antiangiogenic and/or vascularpermeability reducing effect in a warm-blooded animal such as a human,which comprises administering to said animal an effective amount ofAZD2171 or a pharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof, and before, after or simultaneously with aneffective amount of ionising radiation, wherein AZD2171 and ZD6126 mayeach optionally be administered together with a pharmaceuticallyacceptable excipient or carrier.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer in a warm-blooded animal such asa human, which comprises administering to said animal an effectiveamount of AZD2171 or a pharmaceutically acceptable salt thereof, before,after or simultaneously with an effective amount of ZD6126 or apharmaceutically acceptable salt thereof, and before, after orsimultaneously with an effective amount of ionising radiation, whereinAZD2171 and ZD6126 may each optionally be administered together with apharmaceutically acceptable excipient or carrier.

According to a further aspect of the present invention there is provideda method for the treatment of a cancer involving a solid tumour in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof, and before, after or simultaneously with an effective amount ofionising radiation, wherein AZD2171 and ZD6126 may each optionally beadministered together with a pharmaceutically acceptable excipient orcarrier.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an antiangiogenic and/orvascular permeability reducing effect in a warm-blooded animal such as ahuman which is being treated with ionising radiation.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an anti-cancer effect in awarm-blooded animal such as a human which is being treated with ionisingradiation.

According to a further aspect of the present invention there is providedthe use of AZD2171 or a pharmaceutically acceptable salt thereof andZD6126 or a pharmaceutically acceptable salt thereof in the manufactureof a medicament for use in the production of an anti-tumour effect in awarm-blooded animal such as a human which is being treated with ionisingradiation.

According to a further aspect of the present invention there is provideda therapeutic combination treatment comprising the administration of aneffective amount of AZD2171 or a pharmaceutically acceptable saltthereof, optionally together with a pharmaceutically acceptableexcipient or carrier, and the administration of an effective amount ofZD6126 or a pharmaceutically acceptable salt thereof, optionallytogether with a pharmaceutically acceptable excipient or carrier and theadministration of an effective amount of ionising radiation, to awarm-blooded animal such as a human in need of such therapeutictreatment wherein the AZD2171, ZD6126 and ionising radiation may beadministered simultaneously, sequentially or separately and in anyorder.

A warm-blooded animal such as a human which is being treated withionising radiation means a warm-blooded animal such as a human which istreated with ionising radiation before, after or at the same time as theadministration of a medicament or combination treatment comprisingAZD2171 and ZD6126. For example said ionising radiation may be given tosaid warm-blooded animal such as a human within the period of a weekbefore to a week after the administration of a medicament or combinationtreatment comprising AZD2171 and ZD6126. This means that AZD2171, ZD6126and ionising radiation may be administered separately or sequentially inany order, or may be administered simultaneously. The warm-bloodedanimal may experience the effect of each of AZD2171, ZD6126 andradiation simultaneously.

According to one aspect of the present invention the ionising radiationis administered before one of AZD2171 and ZD6126 or after one of AZD2171and ZD6126.

According to one aspect of the present invention the ionising radiationis administered before both AZD2171 and ZD6126 or after both AZD2171 andZD6126.

According to one aspect of the present invention AZD2171 is administeredto a warm-blooded animal after the animal has been treated with ionisingradiation.

In another aspect of the present invention AZD2171 is dosed dailycontinuously for a longer period of time during which time ZD6126 andionising radiation are each administered periodically, that is for a fewdays, for example 1, 2, 3, 4 or 5 days at a time.

According to another aspect of the present invention the effect of amethod of treatment of the present invention is expected to be at leastequivalent to the addition of the effects of each of the components ofsaid treatment used alone, that is, of each of AZD2171 and ZD6126 usedalone or of each of AZD2171, ZD6126 and ionising radiation used alone.

According to another aspect of the present invention the effect of amethod of treatment of the present invention is expected to be greaterthan the addition of the effects of each of the components of saidtreatment used alone, that is, of each of AZD2171 and ZD6126 used aloneor of each of AZD2171, ZD6126 and ionising radiation used alone.

According to another aspect of the present invention the effect of amethod of treatment of the present invention is expected to be asynergistic effect.

According to the present invention a combination treatment is defined asaffording a synergistic effect if the effect is therapeuticallysuperior, as measured by, for example, the extent of the response, theresponse rate, the time to disease progression or the survival period,to that achievable on dosing one or other of the components of thecombination treatment at its conventional dose. For example, the effectof the combination treatment is synergistic if the effect istherapeutically superior to the effect achievable with AZD2171 or ZD6126or ionising radiation alone. Further, the effect of the combinationtreatment is synergistic if a beneficial effect is obtained in a groupof patients that does not respond (or responds poorly) to AZD2171 orZD6126 or ionising radiation alone. In addition, the effect of thecombination treatment is defined as affording a synergistic effect ifone of the components is dosed at its conventional dose and the othercomponent(s) is/are dosed at a reduced dose and the therapeutic effect,as measured by, for example, the extent of the response, the responserate, the time to disease progression or the survival period, isequivalent to that achievable on dosing conventional amounts of thecomponents of the combination treatment. In particular, synergy isdeemed to be present if the conventional dose of AZD2171 or ZD6126 orionising radiation may be reduced without detriment to one or more ofthe extent of the response, the response rate, the time to diseaseprogression and survival data, in particular without detriment to theduration of the response, but with fewer and/or less troublesomeside-effects than those that occur when conventional doses of eachcomponent are used.

As stated above the combination treatments of the present invention asdefined herein are of interest for their antiangiogenic (includingvascular damaging) and/or vascular permeability effects. Angiogenesis,neovascularisation and/or an increase in vascular permeability ispresent in a wide range of disease states including cancer (includingleukaemia, multiple myeloma and lymphoma), diabetes, psoriasis,rheumatoid arthritis, Kaposi's sarcoma, haemangioma, acute and chronicnephropathies, atheroma, arterial restenosis, autoimmune diseases, acuteinflammation, lymphoedema, endometriosis, dysfunctional uterine bleedingand ocular diseases with retinal vessel proliferation includingage-related macular degeneration. Combination treatments of the presentinvention are expected to be particularly useful in the prophylaxis andtreatment of diseases such as cancer and Kaposi's sarcoma. In particularsuch combination treatments of the invention are expected to slowadvantageously the growth of primary and recurrent solid tumours of, forexample, the colon, breast, prostate, lungs and skin. In one aspect ofthe present invention such combination treatments of the invention areexpected to slow advantageously the growth of primary and recurrentsolid tumours of the breast. In one aspect of the present invention suchcombination treatments of the invention are expected to slowadvantageously the growth of primary and recurrent solid tumours of thelung, for example in non-small cell lung cancer (NSCLC). In one aspectof the present invention such combination treatments of the inventionare expected to slow advantageously the growth of primary and recurrentsolid tumours of the kidney. In one aspect of the present invention suchcombination treatments of the invention are expected to slowadvantageously the growth of primary and recurrent solid tumours of thecolon and/or rectum.

In another aspect of the present invention AZD2171 and ZD6126,optionally with ionising radiation, are expected to inhibit the growthof those primary and recurrent solid tumours which are associated withVEGF especially those tumours which are significantly dependent on VEGFfor their growth and spread. Combination treatments of the invention areexpected to inhibit any form of cancer associated with VEGF includingleukaemia, mulitple myeloma and lymphoma and also, for example, toinhibit the growth of those primary and recurrent solid tumours whichare associated with VEGF, especially those tumours which aresignificantly dependent on VEGF for their growth and spread, includingfor example, certain tumours of the colon (including rectum), kidney,breast, prostate, lung, vulva and skin, particularly NSCLC.

The compositions described herein may be in a form suitable for oraladministration, for example as a tablet or capsule, for nasaladministration or administration by inhalation, for example as a powderor solution, for parenteral injection (including intravenous,subcutaneous, intramuscular, intravascular or infusion) for example as asterile solution, suspension or emulsion, for topical administration forexample as an ointment or cream, for rectal administration for exampleas a suppository or the route of administration may be by directinjection into the tumour or by regional delivery or by local delivery.In other embodiments of the present invention the AZD2171 and ZD6126 ofthe combination treatment may be delivered endoscopically,intratracheally, intralesionally, percutaneously, intravenously,subcutaneously, intraperitoneally or intratumourally. Preferably AZD2171is administered orally. Preferably ZD6126 is administered intravenously.In general the compositions described herein may be prepared in aconventional manner using conventional excipients. The compositions ofthe present invention are advantageously presented in unit dosage form.

AZD2171 will normally be administered to a warm-blooded animal at a unitdose within the range 1-50 mg per square metre body area of the animal,for example approximately 0.03-1.5 mg/kg in a human. A unit dose in therange, for example, 0.01-1.5 mg/kg, preferably 0.03-0.5 mg/kg isenvisaged and this is normally a therapeutically-effective dose. A unitdosage form such as a tablet or capsule will usually contain, forexample 1-50 mg of active ingredient. Preferably a daily dose in therange of 0.03-0.5 mg/kg is employed.

ZD6126 will normally be administered to a warm-blooded animal at a unitdose within the range 10-500 mg per square metre body area of theanimal, for example approximately 0.3-15 mg/kg in a human. A unit dosein the range, for example, 0.3-15 mg/kg, preferably 0.5-5 mg/kg isenvisaged and this is normally a therapeutically-effective dose. A unitdosage form such as a tablet or capsule will usually contain, forexample 25-250 mg of active ingredient. Preferably a daily dose in therange of 0.5-5 mg/kg is employed.

It has been reported, in International Patent Application PublicationNo. WO 01/74369, that the effect of a given dose of ZD6126 can beincreased by administering it in divided doses. Divided doses, alsocalled split doses, means that the total dose to be administered to awarm-blooded animal, such as a human, in any one day period (for exampleone 24 hour period from midnight to midnight) is divided up into two ormore fractions of the total dose and these fractions are administeredwith a time period between each fraction of about greater than 0 hoursto about 10 hours, preferably about 1 hour to about 6 hours, morepreferably about 2 hours to about 4 hours. The fractions of total dosemay be about equal or unequal.

For example the total dose may be divided into two parts which may beabout equal with a time interval between doses of greater than or equalto two hours and less than or equal to 4 hours.

ZD6126 may be administered in divided doses when used in combinationwith AZD2171.

Radiotherapy may be administered according to the known practices inclinical radiotherapy. The dosages of ionising radiation will be thoseknown for use in clinical radiotherapy. The radiation therapy used willinclude for example the use of γ-rays, X-rays, and/or the directeddelivery of radiation from radioisotopes. Other forms of DNA damagingfactors are also included in the present invention such as microwavesand UV-irradiation. For example X-rays may be dosed in daily doses of1.8-2.0 Gy, 5 days a week for 5-6 weeks. Normally a total fractionateddose will lie in the range 45-60 Gy. Single larger doses, for example5-10 Gy may be administered as part of a course of radiotherapy. Singledoses may be administered intraoperatively. Hyperfractionatedradiotherapy may be used whereby small doses of X-rays are administeredregularly over a period of time, for example 0.1 Gy per hour over anumber of days. Dosage ranges for radioisotopes vary widely, and dependon the half-life of the isotope, the strength and type of radiationemitted, and on the uptake by cells.

As stated above the size of the dose of each therapy which is requiredfor the therapeutic or prophylactic treatment of a particular diseasestate will necessarily be varied depending on the host treated, theroute of administration and the severity of the illness being treated.Accordingly the optimum dosage may be determined by the practitioner whois treating any particular patient. For example, it may be necessary ordesirable to reduce the above-mentioned doses of the components of thecombination treatments in order to reduce toxicity. The dosages andschedules may vary according to the particular disease state and theoverall condition of the patient. Dosages and schedules may also varyif, in addition to a combination treatment of the present invention, oneor more additional chemotherapeutic agents is/are used. Scheduling canbe determined by the practitioner who is treating any particularpatient.

The present invention relates to combinations of ZD6126 or a saltthereof with AZD2171 or with a salt of AZD2171.

Salts of ZD6126 for use in pharmaceutical compositions will bepharmaceutically acceptable salts, but other salts may be useful in theproduction of ZD6126 and its pharmaceutically acceptable salts. Suchsalts may be formed with an inorganic or organic base which affords apharmaceutically acceptable cation. Such salts with inorganic or organicbases include for example an alkali metal salt, such as a sodium orpotassium salt, an alkaline earth metal salt such as a calcium ormagnesium salt, an ammonium salt or for example a salt with methylamine,dimethylamine, trimethylamine, piperidine, morpholine ortris-(2-hydroxyethyl)amine.

ZD6126 may be made according to the following process.

N-Acetylcolchinol (30.0 g, 83.9 mmol) is dissolved in acetonitrile underan inert atmosphere and 1,2,3-triazole (14.67 g, 212.4 mmol) added via asyringe. Di-tert-butyl-diethylphosphoramidite (37.7 g, 151.4 mmol) isadded and the reaction mixture stirred at about 20° C. to complete theformation of the intermediate phosphite ester. Cumene hydroperoxide(24.4 g, 159.2 mmol) is added at about 10° C. and the reaction mixturestirred until the oxidation is complete. Butyl acetate (50 ml) andsodium hydroxide solution (250 ml of 1 M) are added, the reactionmixture stirred and the aqueous phase discarded. The organic solution iswashed with sodium hydroxide solution (2×250 ml of 1 M) and a saturatedsolution of sodium chloride. Trifluoroacetic acid (95.3 g, 836 mmol) isadded at about 15° C. The reaction mixture is distilled at atmosphericpressure, ZD6126 crystallises and is isolated at ambient temperature.

Salts of AZD2171 for use in pharmaceutical compositions will bepharmaceutically acceptable salts, but other salts may be useful in theproduction of AZD2171 and its pharmaceutically acceptable salts.Pharmaceutically acceptable salts may, for example, include acidaddition salts. Such acid addition salts include for example salts withinorganic or organic acids affording pharmaceutically acceptable anionssuch as with hydrogen halides or with sulphuric or phosphoric acid, orwith trifluoroacetic, citric or maleic acid. In additionpharmaceutically acceptable salts may be formed with an inorganic ororganic base which affords a pharmaceutically acceptable cation. Suchsalts with inorganic or organic bases include for example an alkalimetal salt, such as a sodium or potassium salt and an alkaline earthmetal salt such as a calcium or magnesium salt.

AZD2171 may be synthesised according to the processes described in WO00/47212, in particular those described in Example 240 of WO 00/47212.

The following tests may be used to demonstrate the activity of AZD2171in combination with ZD6126.

Human LoVo Colorectal Carcinoma Tumour Xenografts in Nude Mice

1×10⁷ LoVo tumour cells in 0.1 ml of serum free Dulbecco's ModifiedEagle's Medium (DMEM) were injected subcutaneously (s.c.) into the flankof each athymic (nu/nu genotype) mouse. Tumour volumes were assessed bybilateral Vernier caliper measurement and, taking length to be thelongest diameter across the tumour and width the correspondingperpendicular, calculated using the formula (length×width)×the squareroot of (length×width)×(π/6). Five days after implantation (referred toas “day 0”), when tumours reached a mean volume of 0.8 cm³, mice wererandomised into groups of nine and treated with AZD2171 (3 mg/kg/dayorally, day 0 to day 14), ZD6126 (100 mg/kg/day i.p., day 0 to day 2),or a combination thereof with either “concurrent administration”(AZD2171 day 0-day 14 combined with ZD6126 day 0-day 2, where AZD2171was dosed 2 hours prior to ZD6126) or “sequential administration”(ZD6126 day 0-day 2 followed by AZD2171 day 3-day 14). AZD2171, wasdosed orally at 0.1 ml/10 g body weight, as a suspension in 1%polysorbate 80 (i.e. a 1% (v/v) solution of polyoxyethylene (20)sorbitan mono-oleate in deionised water). ZD6126 was dissolved in asolution of 0.05% sodium carbonate in physiological saline andadministered by intraperitoneal injection at 0.1 ml/10 g body weight.Control animals received AZD2171 vehicle throughout the experiment(orally, day 0-day 14). Inhibition of tumour growth from the start oftreatment was assessed on day 14 by comparison of the differences intumor volume between control and treated groups. In addition, the numberof tumour regressions following 14 days of treatment was ascertained(tumour regression being evident if the tumour volume at day 14 wassmaller than the pre-treatment value on day 0). TABLE I Mean %Inhibition of tumour growth at day 14 Number of tumour (P value by two-regressions evident Treatment tailed t-test) at day 14 AZD2171 (3mg/kg/day, 62% (P < 0.001) 0/9 days 0-14, p.o.) ZD6126 (100 mg/kg/day,65% (P < 0.001) 1/9 days 0-2, i.p.) ZD6126 (day 0-2) + 96% (P < 0.001)2/9 AZD2171 (day 3-14) “Sequential schedule” AZD2171 (day 0-14) + 160%(P < 0.001)  9/9 ZD6126 (day 0-2) (i.e. 60% “Concurrent schedule” tumourregression)

The combination of AZD2171 with ZD6126 produced a greater inhibition oftumour growth than each of AZD2171 and ZD6126 alone. Tumour volumes atday 14 following sequential combination therapy (ZD6126 day 0-2 followedby AZD2171 day 3-14) were significantly smaller than those evident aftertreatment with AZD2171 (day 0-14) or ZD6126 (day 0-2) alone (P<0.001,two-tailed t-test). Tumour volumes at day 14 following concurrentcombination therapy (AZD2171 day 0-14 combined with ZD6126 day 0-2) werealso significantly smaller than those evident after treatment withAZD2171 or ZD6126 alone (P<0.0001; two-tailed t-test) and significantlysmaller than those following sequential combination treatment (P<0.0001;two-tailed t-test). Regression was evident in all LoVo colorectalcarcinoma xenografts at day 14 when the concurrent AZD2171+ZD6126combination schedule was used.

The data is shown graphically in FIG. 1.

1. A method for the production of an antiangiogenic and/or vascularpermeability reducing effect in a warm-blooded animal such as a human,which comprises administering to said animal an effective amount ofAZD2171 or a pharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof.
 2. A method for the production of anantiangiogenic and/or vascular permeability reducing effect in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof, and before, after or simultaneously with an effective amount ofionising radiation.
 3. A method for the treatment of a cancer in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof.
 4. A method for the treatment of a cancer in a warm-bloodedanimal such as a human, which comprises administering to said animal aneffective amount of AZD2171 or a pharmaceutically acceptable saltthereof, before, after or simultaneously with an effective amount ofZD6126 or a pharmaceutically acceptable salt thereof, and before, afteror simultaneously with an effective amount of ionising radiation.
 5. Amethod for the treatment of a cancer involving a solid tumour in awarm-blooded animal such as a human, which comprises administering tosaid animal an effective amount of AZD2171 or a pharmaceuticallyacceptable salt thereof, before, after or simultaneously with aneffective amount of ZD6126 or a pharmaceutically acceptable saltthereof.
 6. A method for the treatment of a cancer involving a solidtumour in a warm-blooded animal such as a human, which comprisesadministering to said animal an effective amount of AZD2171 or apharmaceutically acceptable salt thereof, before, after orsimultaneously with an effective amount of ZD6126 or a pharmaceuticallyacceptable salt thereof, and before, after or simultaneously with aneffective amount of ionising radiation.
 7. A pharmaceutical compositionwhich comprises AZD2171 or a pharmaceutically acceptable salt thereof,and ZD6126 or a pharmaceutically acceptable salt thereof, in associationwith a pharmaceutically acceptable excipient or carrier.
 8. A kitcomprising AZD2171 or a pharmaceutically acceptable salt thereof, andZD6126 or a pharmaceutically acceptable salt thereof.
 9. Use of AZD2171or a pharmaceutically acceptable salt thereof and ZD6126 or apharmaceutically acceptable salt thereof in the manufacture of amedicament for use in the production of an antiangiogenic and/orvascular permeability reducing effect in a warm-blooded animal such as ahuman.
 10. Use of AZD2171 or a pharmaceutically acceptable salt thereofand ZD6126 or a pharmaceutically acceptable salt thereof in themanufacture of a medicament for use in the production of anantiangiogenic and/or vascular permeability reducing effect in awarm-blooded animal such as a human which is being treated with ionisingradiation.
 11. Use of AZD2171 or a pharmaceutically acceptable saltthereof and ZD6126 or a pharmaceutically acceptable salt thereof in themanufacture of a medicament for use in the production of an anti-cancereffect in a warm-blooded animal such as a human.
 12. Use of AZD2171 or apharmaceutically acceptable salt thereof and ZD6126 or apharmaceutically acceptable salt thereof in the manufacture of amedicament for use in the production of an anti-cancer effect in awarm-blooded animal such as a human which is being treated with ionisingradiation.
 13. Use of AZD2171 or a pharmaceutically acceptable saltthereof and ZD6126 or a pharmaceutically acceptable salt thereof in themanufacture of a medicament for use in the production of an anti-tumoureffect in a warm-blooded animal such as a human.
 14. Use of AZD2171 or apharmaceutically acceptable salt thereof and ZD6126 or apharmaceutically acceptable salt thereof in the manufacture of amedicament for use in the production of an anti-tumour effect in awarm-blooded animal such as a human which is being treated with ionisingradiation.